Protein-calorie malnutrition
Protein-calorie malnutrition is called
kwashiorkor.
It
is most common among children living in deprived circumstances.
Treatment takes the form of gradually
improving and balancing the diet.
With
early treatment the prognosis is good, but stunted growth is common.
Prevention of
kwashiorkor can only be assured through a change in the living conditions of the
child and the community.
Alternative
names
protein energy malnutrition, kwashiorkor, protein malnutrition
What is
protein-calorie malnutrition?
Protein-calorie malnutrition is called kwashiorkor. The name
“kwashiorkor” is said to come from
West Africa and means “deposed child”.
Kwashiorkor is a nutritional disorder of children that occurs after a baby is
weaned from the breast. If treated promptly, the prognosis is good, but many
patients have stunted physical development.
Very
underweight children with kwashiorkor are known as marasmic-kwashiorkor.
What causes
kwashiorkor?
Kwashiorkor is essentially a disease of poor socio-economic
conditions. The most commonly accepted cause of kwashiorkor is a low-protein and
inadequate energy (calorie) diet, together with a lack of other nutrients.
Breastfed babies, even those living in impoverished communities, usually receive
sufficient amounts of protein, carbohydrate, fat and other nutrients such as
vitamins in the breast milk. When the child is weaned to an inadequate diet,
kwashiorkor may develop. The situation is exacerbated where disease is rife and
sanitation is poor.
New theories as to what causes kwashiorkor
New theories implicate a lack of other key nutrients, together with
high rates of disease, environmental toxins and general conditions in
overcrowded and poverty-stricken areas. Some researchers have found no relation
between the rate at which children recovered from kwashiorkor and the rate of
re-feeding.
These
new theories, acting alone or in combination, are:
Insufficient
nutrients, including zinc, selenium and vitamins A and E, as well as lack of
protein and fat in the diet.
Aflatoxins
(carcinogenic moulds) in food, which cause an imbalance between free radicals
(unstable molecules that harm healthy cells) generated in the body, and the
protective mechanisms that keep them in check. Moulds or fungi, which grow more
easily on grain foods such as wheat in hot and humid conditions, are thought to
be partly responsible for the contamination of food. This would help to explain
why carbohydrate-dominated diets and kwashiorkor were so closely linked for so
long.
Disease
- which also results in an increased number of harmful free radicals in the
body.
Who gets
Kwashiorkor and who is at risk?
Children living in overcrowded, poverty-stricken conditions are most
at risk of developing kwashiorkor, especially if:
They have recently stopped
breastfeeding, and their diet consists largely of carbohydrates.
Living
conditions are unhygienic.
Conditions in which food is stored or
prepared are unhygienic, allowing it to become contaminated with fungi.
Conditions
encourage the growth and spread of moulds or fungi.
There are frequent outbreaks of
disease in the community.
The child’s immune system is low due
to starvation or disease.
Diarrhoea and dehydration are present.
Symptoms and
signs of kwashiorkor
Early symptoms of kwashiorkor are fairly non-specific. They are
underweight for age. An affected child may at first appear tired, irritable and
disinterested in play. The child fails to grow and loses muscle mass. As
deprivation continues, the child’s legs and body swell up due to the
accumulation of fluid (oedema) in the tissues. A “pot-belly” develops because of
lax abdominal muscles and, in some cases, an enlarged liver.
The hair
becomes sparse, brittle and develops a reddish hue. In severe cases patches of
the skin will slough off leaving oozing sores rather like a burn wound. They are
often anaemic and have heavy worm infestations. Diarrhoeal disease is a frequent
presentation.
Because
of impaired immunity these children are also prone to infections such as
tuberculosis and septicaemia.
Final
symptoms may include coma or shock. If untreated the child will die.
How is
kwashiorkor diagnosed?
The dietary history and clinical examination are usually sufficient
to make a diagnosis.
Blood
tests may be helpful in confirming the diagnosis, but in developing countries
most cases of kwashiorkor are handled by nurses, aid workers or social workers,
who will not have this resource.
Can kwashiorkor
be prevented?
Kwashiorkor is preventable by the provision of a balanced diet,
adequate housing, accessible potable water and proper sanitation together with
economic upliftment.
In order
to grow normally and to remain healthy, a child will need 80-120 kcals/kg per
day for the first few years of life. This is divided so that 9-15% of the daily
energy requirement is protein, 45-55% is carbohydrate and 35-45% is fat. In
general, the lower the fat intake the better.
Vitamin
supplements are also useful.
The
correct storage of food, including grains, should prevent mould from developing.
How is
kwashiorkor treated?
The child with kwashiorkor should be admitted to hospital for the
initial treatment. Unfortunately, this will be impossible in many developing
countries where the disease is most prevalent.
Treatment will depend on the severity of the condition.
Shock,
dehydration and infection will be managed first.
The
child is started on milk feeds. The energy content is increased slowly over a
week or so before solids are introduced.
Milk
only is given for the first five to seven days. An acidified formula is
currently favoured. 80 kcals/kg/day are given for the first three days; 100
kcals/kg/day the next three days and then 150-200 kcals/kg/day thereafter. The
energy content of feeds can be increased by the addition of sunflower seed oil
(5 ml/100 ml milk) or glucose polymer (max 10 ml/100 ml). Solids (e.g. cereals,
mince) are introduced from about day six. In general, the more severe the
condition the slower the feeds are increased.
Some
children may develop lactose intolerance. This is the inability to digest the
carbohydrate in milk. Lactose free milks are then tried e.g. Soya milk.
Antibiotics are given and the child should be de-wormed.
Vitamin
supplements must be given for a number of months.
The
anaemia is treated with iron tonic when the child is in the recovery phase.
The
Department of Health has a National feeding policy, the PEM scheme
(Protein-Energy Malnutrition), to assist in the nutritional rehabilitation of
malnourished children. The scheme is administered through the local clinics.
What is the
outcome of kwashiorkor?
The majority of children will recover if treatment is started early
although many will not attain normal physical growth levels. Some children are
so severe when they present that they die from the disease or its many
complications.
Children
under seven months of age who develop severe kwashiorkor may end up with some
intellectual impairment.
Development is delayed due to lack of the nutrients and protein essential for
optimum brain growth. It is also delayed because malnourished children have less
energy to play and explore their environment.
Even if
treated, relapses will result in stunted mental and physical development.
Recurrence is likely unless the child’s environment is drastically altered.
Education of caregivers and the community can assist in the long-term prevention
of kwashiorkor.
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